The Four Pillars of Injury: What's Actually Causing Your Musculoskeletal Pain
⌚️ read time: 5.7 minutes
When you’re injured, all you want is for the pain to go away.
Or to rewind the clock and undo whatever fatal mistake led to your injury.
As an orthopedic surgeon, I've spent years with a front-row seat to people’s injury patterns. And it turns out that a high percentage of injuries aren't just random bad luck.
Whether you're dealing with tennis elbow, a rotator cuff tear, or a sprained ankle, many orthopedic problems can be traced back to one of four fundamental causes. Wouldn’t it be nice to know in advance how to improve your odds of staying in the game?
The Four Pillars of Injury
Understanding these four root causes isn't just academic — it's the key to both preventing injuries and recovering properly when they do occur. Let's break them down.
The Eccentric Contraction
I want you to bookmark this one in your mind.
If you pay attention, it happens all throughout the day, and it’s constantly putting you at risk for injury.
Tune into your muscles, and you’ll feel this one:
Carrying too many grocery bags in from the car at once
Wrestling a toddler into pajamas or a car seat
Feeling rushed at the airport and lurching your bag onto the security belt
Reaching in the back seat with one arm to grab your bag
This list could actually be endless
Remember how muscles work? They contract to generate force. But what many people don't realize is that muscles must also control motion in the opposite direction — what we call eccentric contractions.
When you lower a weight slowly (like the "negative" part of a bicep curl), your muscle is actually lengthening while still contracting. This creates tremendous tension, far more than during the concentric lifting phase.
Because these eccentric contractions generate extreme forces in your musculoskeletal system, most tears happen during this phase. Whether it's an athlete rupturing his Achilles during a quick direction change on the pickleball court, a weightlifter tearing a pectoralis major muscle while lowering a heavy bench press, or a weekend warrior feeling that concerningly-sharp strain in her rotator cuff as she reaches into the backseat to grab her gym bag, these injuries lurk around every corner.
The point is, these don’t just happen at the gym.
When you’re off balance, carrying just a bit too much, or grabbing an object in an unusual position, all your surrounding muscles have to work overtime to stabilize you. And if you’re off just a little bit, that stabilizing muscle might tip over the edge from eccentric contraction to tendon/muscle tear.
And that’s game over.
Like I said. Bookmark this one. Start finding and eliminating these little tweaks in your daily life, and you will drastically improve your musculoskeletal health.
You’ll see, this cause actually filters through the remaining three pillars below.
The Training-Load Mismatch
The human body has incredible potential.
It can adapt to handle tremendous loads, but only if it's been properly trained for them. When the load exceeds what your tissues have been prepared to handle, something breaks.
This mismatch between training and actual demands is behind countless injuries I see.
No surprise to anyone, the classic example is the "weekend warrior" — sedentary Monday through Friday, then suddenly playing full-court basketball on Saturday.
Or the office worker who normally lifts nothing heavier than a coffee mug, then helps a friend move furniture.
But this mismatch isn't just about intensity — it's also about specific movements. Consider a skilled weightlifter who injures his shoulder helping his child on the monkey bars. Despite being "strong," he hadn't trained his shoulders for that specific movement pattern and load angle.
And just as described above, the body gets in a position it’s not ready for, all of the stabilizing muscles activate via eccentric contraction…and something tears.
Your tissues adapt specifically to the demands you place on them. No demand, no adaptation.
Sudden demand without adaptation? That's when injuries happen.
The Recovery Deficit
"No pain, no gain" might be the most dangerous phrase in fitness.
While pushing your limits is absolutely necessary for improvement, inadequate recovery is a silent killer for your musculoskeletal system.
And recovery isn't just about feeling less sore. It’s about allowing your tissues to build themselves back stronger. Skip this crucial phase, and you're setting yourself up for trouble.
This happens regularly with runners who increase their mileage too quickly or exercise enthusiasts who train the same muscle groups day after day. While the first few workouts might feel fine, this pattern creates microscopic damage that accumulates until something gives.
And it’s usually that one tired, uncontrolled eccentric contraction that will do you in.
But fear not.
Your body sends plenty of warning signals: mild pain, stiffness, decreased performance, difficulty getting out of bed in the morning.
But many people push through these rather than recognizing them as recovery deficit warnings.
My tip? If you're driven to train every day, make sure you are appropriately varying the muscles worked and types of workouts (eg, cardio one day, resistance training the next).
The Biomechanical Imbalance
This one is probably the hardest to feel in your own body. But rest assured, it’s there.
Our bodies function best when everything works in balance. Proper biomechanics means that forces are distributed optimally across joints and tissues. As an example, you want your quads as strong as your hamstrings to prevent off-balance loads across your knee joint.
But life creates imbalances. And now more than ever.
Let’s be honest. For the average person, most of life happens directly in front of us — sitting, hunched over, and firing our fingers across a keyboard or screen.
Just imagine for a moment what that does to your muscles. More specifically, what that does to half your muscles. Your front-side muscles.
Inevitably, half your muscles will become overly tight while the other half weaken, progressively altering your movement patterns and placing abnormal stresses on your tendons, ligaments, and joints.
And by abnormal stresses, what do I really mean? Uncontrolled eccentric contractions that put you at high risk of injury.
Consider the common scenario of an athlete with persistent elbow pain who had tried everything — for the elbow, that is.
The real problem wasn't in the elbow at all, but instead was a combination of poor shoulder mobility and weak stabilizing muscles, creating abnormal forces and over-compensation down the kinetic chain.
Once the biomechanical issues were addressed in therapy (“Doc, I’m an athlete in the gym every day, I don’t need therapy”), the elbow symptoms simply melted away.
Takeaways:
Most musculoskeletal pain stems from one or more of these four fundamental “Pillars of Injury”
Eccentric contractions produce the highest forces in your muscles and are a common cause of musculoskeletal injury
Awareness of these four causes of musculoskeletal injury will put you leaps and bounds ahead in terms of your ability to stay off the sidelines and out of the doctor’s office
Next time you experience pain or discomfort during activity, consider which of these four factors might be contributing.
Better yet, now that you know what to look out for, take a proactive approach by addressing these areas before they lead to injury.
Your future self will thank you.
